Severe Mental Illness Patients Research Articles

EPA-0301 – Improving somatic health of outpatients with severe mental illness

Introduction Patients with severe mental illness (SMI) experience a 13- to 30-year reduction in life-expectancy. The majority of these deaths can be attributed to somatic health problems. The risk on somatic health problems is partly increased due to a reduced ability to request care and a health care organisation that is unable to fulfil the needs of these patients. Our previous work shows that a health-check-intervention can bypass the inability to request help of patients with SMI by detecting somatic healthproblems that were not detected previously[1]. Objectives To develop policy-recommendations to improve the health care organisation for the physical health of outpatients with SMI. Aims We aim to present a selection of policy-recommendations based on consensus between patients, family carers, general practitioners(GP) and mental health care staff Methods We used a three-round Delphi method. The first round consisted of an inventory of potential policy-recommendations, in the two consecutive rounds consensus was sought on a selection of recommendations. Results The policy recommendations described improvement in collaboration among health care professionals; the need to educate involved professionals regarding the specific medical risks associated with patients with SMI; and defining the differences between GPs and mental health care professionals regarding their responsibilities to provide adequate care for the physical health of SMI patients. Conclusions Currently there are multiple barriers to optimal health care which can be overcome by implementing the suggested policy recommendations.

Risk Assessment of Mentally Ill Patients are Urgently Needed in China

It is one of the main tasks of forensic psychiatry to reduce risk behaviors in mentally ill patients through risk assessment and management. Because of the subjectivity of mental disorders diagnosis and the complexity of disease itself, how to assess dangerous behavior or risk in patients with mental disorder is critically important. Relevant successful experience shows that the risk of violence in mentally ill patients can be predicted relatively accurately and controlled to some extent. Violence risk assessment has been put into mental disorders treatment guidelines by American Psychiatric Association and the British National Institute for Health and Clinical optimization [5,6]. Structured risk assessment tools such as HCR-20 have been regularly used for assisting in violence risk assessment of patients (and offenders) in some developed countries, and are often used to justify the long periods of detention [7-9]. Many patients are discharged if they at low level of risks, but much of these instruments are based on static or unchangeable risk factors, which mean that their level of risk will not materially change with treatment. Nevertheless, these tools provide some means to assist forensic psychiatrists to make these difficult decisions regarding detention and discharge. The Chinese violence risk assessment is still in its infancy and lack of systematic research and evidence based risk assessment tools for mentally ill patients. Bin Xie, etc. introduced MOAS (Modified Overt Aggression Scale) and conducted the rater consistency to the Chinese version of MOAS [10]. My research team brought in HCR-20 (The Historical Clinical Risk Management) and carried out a preliminary study of the reliability and validity about it [11]. Xueli Zhang, et al. revised violence Risk Scale (VRS) for assessing violence risk and risk change, and examined the reliability of this modified Violence Risk Scale in Chinese version (VRS-C) [12]. However, because such assessment tools need specialized training and take long time to finish the evaluation, they are still in the research stage. No debate on the actuarial vs. structured professional judgment has been found so far. The Disease Prevention and Control Center in Chinese Health Ministry issued a Severe mental disorders management norms in 2009 and classified the violence risk of severe mental disorders into 6 levels from light to heavy. But no validity and reliability data was provided in Chinese patients. Therefore, it is an urgent task currently to establish a relatively objective, quantifiable, operational assessment model or tool based on evidence. The model of the tool can be used for accurate assessment and prediction the risk of mentally ill patients. The Chinese forensic psychiatry experts mostly adopt unstructured clinical assessment to estimate violent risk of mentally ill patients based on investigation, history taking and clinical examination. This method advantage is to make individual assessment and the disadvantage is not very objective and less systematic. Different institution even different experts in the same institution may obtain different conclusions by the unstructured clinical assessment, which means the psychiatrists make the judgments based on their own clinical experience and makes it difficult to compare the assessment opinions. A few scholars specializing in forensic psychiatry or psychologists advocate the actuarial assessment or structured professional judgment. Therefore, it is necessary to develop a shared risk assessment model or tool for Chinese forensic psychiatry experts to reach a coincident opinion in one case as much as possible. But there are enormous complicated variables involved in risk assessment such as biological and psychological characteristics, environmental influence from family and society, types of violence, incentives, illness situation, etc. [13]. It is very difficult task to design a shared assessment model or tool with considering so many factors in so urgent time to promote better implementation of China Mental Health Act and the amended Criminal Procedure Law. While it is a reasonable way to develop a risk assessment checklist, particularly focusing on modifiable risk factors based on previous research. Katrina Witt, etc. found that those four factors had a high correlation with violence risk including the conduct of hostilities, the recent substance abuse and alcohol abuse history, treatment non adherence, history of crime and violence. And they also found that the four factors could predict violence risk through a systematic literature review of 110 studies and meta-analysis [14]. At the same time, set up a database for severe mental illness patients in China and then revise the shared risk assessment checklist. Eventually China will develop a management protocol for mental illness patients based on their different level of risk and will have a profound risk assessment tool or model to promote reasonable and effective disposal, prevention and surveillance services for the mentally ill patients. Language: en

The motivation paradox: higher psychosocial problem levels in severely mentally ill patients are associated with less motivation for treatment

Lack of motivation for treatment makes a subgroup of patients with severe mental illness (SMI) difficult to engage in psychiatric treatment. Such difficult-to-engage patients may also be the most in need of treatment. We hypothesized that the level of psychosocial problems would be inversely related to motivation for treatment. Cross-sectional study in two independent samples. The first sample (n=294) included SMI patients who participated in a randomized controlled trial and were assessed using the Health of the Nation Outcome Scales (HoNOS) and self-rated and clinician-rated motivation-for-treatment scales. The second sample (n=1,170) included SMI patients who were treated in Assertive Outreach Teams and were routinely assessed with the HoNOS and a motivation-for-treatment scale. In both samples, patients also self-rated their quality of life. In both samples, patients with HoNOS scores of 16 and higher had lower motivation scores on all motivation scales than patients with lower HoNOS scores, and also a lower quality of life. A motivation paradox seems inherent to this association between higher psychosocial problems levels, less motivation for treatment, and lower quality of life. Such a paradox has clinical relevance, as it may provide an ethical basis for outreach services which aim to engage marginally motivated SMI patients with severe psychosocial problems into mental health care.

The availability and quality across Europe of outpatient care for difficult-to-engage patients with severe mental illness: A survey among experts

As many patients with severe mental illness (SMI) who have complex needs are difficult to engage, outreach mental health services are needed to engage them into treatment. The extent to which these services exist in large European cities is unknown. Experts in 29 European countries were sent a structured questionnaire containing two case vignettes of difficult-to-engage patients (a first-episode psychosis patient and a homeless chronic schizophrenia patient). The type and quality of outpatient care was assessed and related to several national indices. The questionnaire was returned by experts from 22 countries (76%) representing 92% of the EU population. Six countries (21%) had a systematic method for detecting difficult-to-engage patients. The most important route whereby such patients entered the mental health system was through informal care; the most important reasons for entering it were the level of psychiatric symptoms, nuisance and violence. Assertive outreach was available in nine countries (41%), with coverage ranging from a few teams (sometimes for a specific target group) to most of the country. The case vignettes showed that outpatient care for these difficult-to-engage patients varied widely. In seven (30%) of the 22 countries, a hospital would take no action if such patients who had been admitted voluntarily discharged themselves prematurely. On a scale of 0-10, the experts' mean scores regarding the quality of outpatient care for patients with SMI in general were 5.2 (SD = 1.9) and 3.2 (SD = 2.2) in difficult-to-engage ones. Explorative analyses showed that the quality of outpatient care for difficult-to-engage patients was associated with gross national income and the number of psychiatrists per capita. Outpatient mental health services for difficult-to-engage SMI patients varied widely among European countries; experts judged their overall quality to be poor. It is now important to achieve consensus on a minimum European standard for the quality of care for such patients.

Screening for cardiovascular risk in patients with severe mental illness in primary care: A comparison with patients with diabetes

BackgroundPeople with severe mental illness (SMI) have a higher risk of developing cardiovascular disease (CVD) compared with the general population. Clinical guidelines recommend annual screening for CVD risk factors with appropriate lifestyle counselling.AimsTo establish the proportion of patients with SMI being screened for CVD risk factors in their primary care practice compared with those with diabetes and determine whether people with SMI receive lifestyle advice.MethodDesign: a retrospective audit. Setting: five primary care centres in Northampton, England. Participants: three hundred and eighty-six patients with SMI and 1875 with diabetes.ResultsJust over a fifth of patients with SMI received a full CVD screen compared with the 96% of those with diabetes (OR = 90.37; 95% CI = 64.53–126.55, p < 0.01). Fifty-seven per cent of the SMI patients were given smoking advice but only 13% and 14% received guidance regarding diet and exercise, respectively. On average of each patient with SMI received fewer than two (from four) screening interventions and less than one (from three) components of lifestyle advice.ConclusionsIn primary care, the number of people with SMI receiving screening for CVD risk is much lower than those with diabetes.

Screening for obstructive sleep apnea among individuals with severe mental illness at a primary care clinic

ObjectiveObstructive sleep apnea (OSA) is linked to significant morbidity and mortality. OSA has received more attention recently, but the literature on OSA is scant in patients with severe mental illness (SMI). This project was undertaken to improve clinician knowledge and screening of OSA in persons with SMI. MethodOne hundred SMI patients attending a primary care clinic were screened for symptoms and risk factors associated with OSA. The Epworth Sleepiness Scale was used to assess daytime sleepiness, and the STOP-Bang score was used to classify those at high risk for OSA. ResultsSixty-nine percent of patients were found to be at high risk for OSA. Sixteen percent had a previously confirmed diagnosis of OSA. Most patients reported that OSA was never discussed with them, and 71% of those at high risk were willing to be referred for a sleep evaluation. ConclusionsPatients with SMI are at high risk for OSA, and screening for OSA appears to be inadequate. This screening can be done easily, seems acceptable to patients and may prove very beneficial as OSA diagnosis and treatment can improve mental and physical health outcomes in SMI patients.

Vitamin D insufficiency in obese patients with severe mental illness taking olanzapine

The purpose of the study was to assess the vitamin D status of obese patients with severe mental illness (SMI) treated with olanzapine. Fifteen obese SMI patients treated with olanzapine were pair-matched with healthy obese subjects. Another 52 overweight and obese SMI patients volunteered to participate in the study (total n = 67) and were divided into three subgroups (group A = overweight, group B = obese, group C = severely obese). Anthropometric, body composition, blood glucose, lipids, 25(OH)D, intact parathyroid hormone, and calcium measurements were performed. No differences were found between healthy and SMI subjects in any of the dependent variables (p > 0.05). The obese and severely obese patients demonstrated significantly lower levels of serum 25(OH)D concentration (p < 0.01) compared with overweight. A significant inverse correlation was found between serum 25(OH)D concentration and all anthropometric parameters (p < 0.05). The results indicate that obese SMI patients appear to be vitamin D deficient, similar to healthy obese subjects. The level of obesity seems to play a significant role in their vitamin D status: the greater the body fat of the patients the lower the serum 25(OH)D concentration. Thus, as in healthy individuals, an inverse association exists between the degree of adiposity and the serum 25(OH)D concentration in SMI patients

The Need to Develop Innovative Interventions to Improve Treatment Adherence in Co-Occurring Severe Mental Illness and Substance Use Disorders

Treatment nonadherence is a significant public health problem that spans medical and psychiatric populations, adding billions of dollars to healthcare costs [1]. Patients with chronic and severe mental illness (SMI), such as schizophrenia and bipolar disorder, as well as those with substance use disorders (SUDs) tend to exhibit high rates of nonadherence (e.g., 50% or greater) to their medication and psychosocial treatments [2-7]. Not surprisingly, then, nonadherence rates tend to be highest in SMI patients who also abuse drugs or alcohol compared with noncomorbid patients [8]. Nonadherence in co-occurring SMI and SUDs produces a host of negative consequences, including increased rates of relapse, hospitalization, suicide, and functional impairment [5,9-11]. Abrupt withdrawal from psychotropic medications for SMI can lead to a quick return of symptoms that is not just attributable to the original illness, but also due to potential rebound effects associated with withdrawal from medications [12,13]. Furthermore, premature treatment drop out averages 50% within the first few weeks of SUD treatment [4-6], which prevents early intervention that can alter illness trajectories and provide needed course corrections prior the development of clinical crises. Nonadherence also contributes to the so-called “efficacy-effectiveness gap” [14]. We spend large amounts of money and resources developing efficacious mental health treatments, but these interventions will have little public health impact unless patients view them as acceptable and adhere to them.

A Motivational Interviewing Group to Manage Cardiometabolic Risk on an Inpatient Psychiatry Unit

To the Editor: People with severe mental illness face an increased risk for disability and death from medical conditions; those with schizophrenia die 25 years earlier than age-matched controls.1 The leading cause of excess mortality is cardiovascular disease in both schizophrenia and mood disorders.2 This increased morbidity and mortality is in part explained by the fact that patients with severe mental illness carry a 1.5–2 times higher prevalence of modifiable risk factors such as dyslipidemia, hypertension, and obesity.1 Motivational interviewing (MI) is an effective means of improving health behaviors. A meta-analysis of 72 clinical trials concluded that MI promotes improved adherence to diet and exercise programs.3 However, MI for this purpose is not widely available. Method. A weekly MI group was developed to address patients' ambivalence toward changing their health behaviors at a 230-bed state psychiatric facility with an average length of stay of 7 days and 2,100 admissions per year. Patients were invited on the basis of meeting diagnostic criteria for metabolic syndrome determined by universal lipid and glucose screening, or carrying a medical diagnosis of a coronary artery disease risk equivalent.4 A psychologist and a licensed recreational therapist co-lead this group. Each session consists of a brief goal-setting discussion, a review of prior participants' progress on their goals, and an invitation to new members to share thoughts on health behavior change. Ten-point Likert scales help members clarify the importance of the changes and their confidence in making them. Results. Medical records of patients who attended this group over 14 months were reviewed in July 2009. A total of 48 patients attended, with a mean of 2.2 encounters per patient. The mean age was 47 years; 24 patients were women and 71% (n = 34) were smokers. The most frequent medical diagnosis was diabetes (n = 22), followed by hypertension (n = 20) and hyperlipidemia (n = 18). Mean body mass index (BMI) was 32 (kg/m2). The most common DSM-IV diagnoses were schizoaffective disorder and bipolar disorder (n = 15 each), followed by major depression (n = 7). The most frequent goal was to increase exercise (n = 7), followed by improving diet (n = 4) and losing weight (n = 4). Data from the 10 patients who attended more than 3 groups were analyzed. Six of the 10 patients had a BMI over 30. According to the group leaders' notes, 7 patients advanced at least 1 Prochaska stage5 of change over their time in the group. One patient listed smoking as a behavior change goal, and 6 picked a diet or exercise goal. This MI-based health behavior group for severe mental illness patients in an involuntary psychiatric hospital is feasible and appeared to facilitate movement along the Prochaska stages of change for various health behaviors. Further research is warranted.

Cognitive Impairment and Perceived Stress in Schizophrenic Inpatients with Post-Traumatic Stress Disorder

The rate of lifetime traumas in the general population is high and a great deal of evidence suggests that persons with severe mental illness (SMI) show an even higher degree of vulnerability to trauma throughout their lives. Recent studies report between 13 and 29% of comorbid Post-Traumatic Stress Disorder (PTSD) in schizophrenic patients. Other studies showed that SMI patients with PTSD were in poorer health, had lower self-esteem, and had lower subjective quality of life and more cognitive deficits in comparison with those without PTSD. The aim of this work is to study a sample of chronic schizophrenic inpatients admitted after the L'Aquila earthquake, to assess if comorbid PTSD is associated with a higher rate of neurocognitive deficit and poorer quality of life in comparison with schizophrenic inpatients without PTSD. The sample of this study, recruited after the L'Aquila earthquake (between April 2009 and December 2009), consisted of 54 schizophrenic earthquake survivors admitted consecutively to the Psychiatric Inpatients Unit of L'Aquila San Salvatore Hospital. Each patient was assessed with the Positive and Negative Syndrome Scale (PANSS) and the General Health Questionnaire − 12 items (GHQ-12). The Impact of Event Scale-Revised (IES-R) was used to grade post-traumatic symptoms. PTSD diagnosis was made with the Structural Clinical Interview for DSM-IV (SCID-I). The cognitive assessment battery included WAIS-III Digit Span and Trail Making Test to assess working memory and executive functions, respectively. The severity of illness was measured with the Clinical Global Impression Scale (CGI). All the patients were on antipsychotic drugs at a mean daily chlorpromazine-equivalent dose of 236.38 mg (SD 183.5). 17% of the 54 schizophrenic inpatients (n 9) met the DSM-IV criteria for PTSD. PTSD subjects had significantly higher scores on the PANSS Positive Symptom subscale (P ≤ 0.015) and higher GHQ-12 mean score (30.50 vs 16.93). In the presence of post-traumatic symptoms a significant difference between the two groups (with and without PTSD) was found in hyper-arousal subscale scores, with a significant impairment of working memory in the PTSD sample. PTSD symptom measures positively correlated with the PANSS total and Positive score and GHQ-12 score &gt; 20 (“high stress level”). PTSD in schizophrenic patients is associated with a more severe cognitive deficit, higher levels of perceived stress and more positive symptoms. The investigation of PTSD in patients with schizophrenia might have important implications for their clinical management and for future research.

Systematic monitoring of needs for care and global outcomes in patients with severe mental illness

BackgroundIt was hypothesised that the introduction of tools that allow clinicians to assess patients' needs and to negotiate treatment (Cumulative Needs for Care Monitor; CNCM), would be associated with global outcome improvements in patients diagnosed with severe mental illness.MethodsThe CNCM was introduced in one region in South Limburg (the Netherlands) in 1998 (REGION-1998) and in the rest of South Limburg in 2004 (REGION-2004). By comparing these two regions, changes after the introduction of the CNCM could be assessed (between-region comparison). In addition, a pre-post within-patient comparison was conducted in both regions.ResultsThe within-patient comparison revealed that global outcomes of psychopathology and impairment improved in the first 3-5 years after the introduction of the CNCM. The between-region comparison revealed an improvement in global psychopathology but not in global impairment in REGION-2004 after 2004, while there was no such improvement in REGION-1998.ConclusionSystematic clinical monitoring of individual severe mental illness patients, in combination with provision of feedback, is associated with global improvement in psychopathology. More research is needed to determine the degree to which this association reflects a causal effect.

The cumulative needs for care monitor: a unique monitoring system in the south of the Netherlands

IntroductionPatients diagnosed with severe mental illness (SMI) have a complex combination of psychiatric, somatic and social needs for care, requiring an integrated, multidisciplinary health care approach. The present paper describes the methods of the cumulative needs for care monitor (CNCM), a monitoring system in operation in a geographically defined area.MethodsThe CNCM provides information on need for care, functioning and other outcomes in SMI patients in the area. This information can be used not only to plan treatment at the individual level, but also to conduct health services research at the group level.

Weight management by modular group interventions. Outcome at 24 months in an Irish cohort with severe mental illness (SMI)

Background and Aims:Patients with SMI receive long term intervention with psychotropic agents often associated with weight gain. Weight and lifestyle management programmes may prevent, reduce or reverse weight gain, however most data is short-term. Categorical data is not often reportedMethods:A group programme (Solutions for Wellness) designed to address weight and other cardiovascular risk factors commenced 2002 in Ireland. Each group provided open-ended access to referred SMI patients. Weekly group sessions consisted weighing, discussion and an 8-week rotational cycle of educational topics on aspects of weight, dietary choices and lifestyle changes. Groups were led by trained healthcare professionals.Results:Data is reported up to 24 months from 55 patients (27 male; 28 female) from 6 centres. Mean age 49.4 years (range 21-74). Schizophrenia 63%, Affective disorders 26%, other 11%. Patients completing 1 year - 55% and 2 years 22%. Baseline mean weight 98.6 kg (SD 19.2) decreased to final visit weight 96.9kg (SD 18.4).Paired t –test, p = 0.0030; CI Mean 2.53 (0.9-4.159). Weight increased in 11/55, maintained 7/55 and decreased 37/55.Conclusions:Weight gain in SMI patients is not inevitable and was found in only 20% of patients attending weight clinics in Ireland. Patients may benefit if similar interventions were widely available.

Categorical prevalence and severity of hyperprolactinaemia in two UK cohorts of patients with severe mental illness during treatment with antipsychotics

Hyperprolactinaemia may be associated with hidden longer-term consequences, such as osteoporosis, bone fractures, pituitary tumours and breast cancer. Prolactin data from clinical trials is not always reported in a categorical manner and does not always allow the risk of hyperprolactinaemia to be evaluated for specific patient cohorts. Patients participating in a physical health management programme in the UK for severe mental illness patients--the Well-being Support Programme--had prolactin measurements made regardless of symptoms. Prolactin data from the complete cohort of 178 patients receiving antipsychotics in Leeds and London are reported. Hyperprolactinaemia was measured in 33.1% but more commonly in females than males (47.3% and 17.6%) and was associated with all antipsychotics except clozapine. The highest prevalence rates were found in amisulpride (n=20) 89%, risperidone long-acting intramuscular injection (LAIM) 67% (n=6) and risperidone (n=30) 55% used as antipsychotic monotherapy. Clinically Significant hyperprolactinaemia (>1000 mIU/L approximately 47 ng/ml) was measured in 15.8% of patients, predominantly in females. Levels >2000 mIU/L approximately 95 ng/ml in 6.2% of the complete cohort. Clinicians may wish to add prolactin measurement to the routine laboratory parameters currently measured for some antipsychotics and should be advised of the potential longer-term consequences of hidden hyperprolactinaemia.

A well-being programme in severe mental illness. Baseline findings in a UK cohort

Introduction:Patients with severe mental illness (SMI) have higher rates of cardiovascular disease (CVD) morbidity and mortality than the general population. In the UK, data were limited regarding the known prevalence of physical health screening of SMI patients.Aims:A total of 966 patients with SMI from seven geographically varied regions in the UK agreed to participate in a 2-year nurse-led intervention (Well-being Support Programme), designed to improve their overall physical health by providing basic physical health checks, health promotion advice, weight management and physical activity groups in secondary care.Results:At baseline, only 31% of participants had undergone a recent physical health check. There were high rates of obesity (BMI > 30 in 49%), glucose abnormalities (12.4%), hypertension/prehypertension (50%), hyperlipidaemia (71%), poor diet (32%), low exercise levels (37.4%) and smoking (50%).Conclusions:Patients with SMI where healthcare professionals have concerns regarding their physical health, have potentially modifiable risk factors for CVD, which remain undiagnosed. Programmes designed to address the physical health problems in SMI need to be implemented and evaluated in this already marginalised group of people.

A well-being programme in severe mental illness. Reducing risk for physical ill-health: A post-programme service evaluation at 2 years

Introduction Cardiovascular disease is more prevalent in patients with severe mental illness (SMI) than in the general population. Method Seven geographically diverse centres were assigned a nurse to monitor the physical health of SMI patients in secondary care over a 2-year period in the “Well-being Support Programme” (WSP). A physical health screen was performed and patients were given individual weight and lifestyle advice including smoking cessation to reduce cardiovascular risk. Results Nine hundred and sixty-six outpatients with SMI >2 years were enrolled. The completion rate at 2 years was 80%. Significant improvements were observed in levels of physical activity ( p < 0.0001), smoking ( p < 0.05) and diet ( p < 0.0001). There were no changes in mean BMI although 42% lost weight over 2 years. Self-esteem improved significantly. Low self-esteem decreased from 43% at baseline to 15% at 2 years ( p < 0.0001). At the end of the programme significant cardiovascular risk factors remained, 46% of subjects smoked, 26% had hypertension and 81% had BMI >25. Conclusion Physical health problems are common in SMI subjects. Many patients completed 2 years follow up suggesting that this format of programme is an acceptable option for SMI patients. Cardiovascular risk factors were significantly improved. Interventions such as the Well-being Support Programme should be made widely available to people with SMI.

Substance abuse and quality of life among severely mentally ill consumers

Evidence suggests that substance abuse negatively affects both psychiatric symptom severity and quality of life (QOL) in people with severe mental illness (SMI). However, these relationships have not been examined simultaneously, nor have they been characterized over time. Thus, it is difficult to appreciate the extent to which substance abuse exerts an enduring effect on psychiatric symptoms and distress and/or QOL in this population. The purpose of this study is to test a conceptual model linking these factors together. Subjects were participants in a longitudinal evaluation of community mental healthcare in Ontario (n = 133). Comprehensive consumer assessments were conducted at treatment entry, and at 9 and 18 months. Subjects were receiving intensive case management or assertive community treatment throughout the 18-month study period. Structural equation modelling was used to examine the concurrent and longitudinal relationships between substance abuse, symptoms and distress, and QOL. The prevalence of substance abuse was 55.0%. The SEM analysis suggested that substance abuse at baseline was associated with elevated symptomatology and distress and lower QOL, and that these effects endured after 18 months of treatment. Psychiatric symptoms and distress mediated the negative relationship between substance abuse and QOL. The mediating role played by symptom and distress levels in the relationship between substance abuse and QOL suggests the importance of closely monitoring changes in these factors among SMI patients with substance problems. Tracking symptom severity and distress levels over time will allow service providers to intervene and potentially improve the QOL of individuals with SMI.

Psychopathology and alexithymia in severe mental illness: the impact of trauma and posttraumatic stress symptoms

To empirically investigate whether or not symptoms of posttraumatic stress disorder (PTSD) are essential for transferring the negative effects of trauma on the severity of severe mental illness (SMI) as recently suggested by an interactive model. About 122 inpatients with either schizophrenia or major affective disorder were administered the Posttraumatic Diagnostic Scale, the Symptom Checklist and the Toronto Alexithymia Scale. At least one trauma was reported by 83 participants (68%) and 28 patients (23%) reported symptoms of current PTSD. Those SMI subjects with current PTSD symptoms had significantly more psychopathological distress and alexithymic features than those with a trauma exposure but without PTSD symptoms and those patients without any traumatic experiences. In line with prior research, our data indicate that patients with SMI have frequently been exposed to traumatic events and that a third suffers from current posttraumatic stress symptoms. Despite some methodological limitations our findings support the interactive model, which posits that a comorbid PTSD increases the symptom severity of SMI. More attention should be directed at assessing trauma and PTSD in SMI patients and at developing therapeutic interventions.

Estimating the Prevalence of Severe Mental Illness in Mental Health Services in Lombardy (Italy)

Although many countries' policies give Severe Mental Illness (SMI) priority inside Mental Health Services, researches assessing the prevalence of SMI in Mental Health Services according to operational criteria are still few. The aim of this is paper is to define annual SMI treated prevalence, describing socio-demographic and clinical characteristics, patterns of care and treatment costs of SMI and non-SMI patients. SMI prevalence in 10 Departments of Mental Health of the Lombardy Region (Italy) was assessed in 2000 by applying criteria concerning both severity, measured through HoNOS (Health of the Nation Outcome Scales), and utilisation patterns in the previous year. Annual SMI prevalence was equal to 3.1 cases per 1,000 inhabitants aged over 14; SMI patients' costs were 5.5 times higher than those of non-SMI patients ($5,183 versus $939 per year) and patterns of care were different. The variables predicting the SMI status were diagnosis, presence of paid employment, duration of service contact, care packages delivered in 2000 and severity of some HoNOS items (self harm, drug abuse, cognitive problems, delusions, other symptoms, relationships, activities of daily living and housing). The use of the combined criteria of severity and intensity of contact with mental health services in the previous year seems to be able to define severely ill patients adequately.

Hepatitis C virus and HIV co-infection in people with severe mental illness and substance use disorders

The 5-7% of adults in the United States with severe mental illness (SMI), especially the 50% who are 'dually diagnosed' with co-occurring substance use disorders (SUD), are at an elevated risk of HIV and hepatitis C virus (HCV). However, little is known about HIV/HCV co-infection in this population. This paper examines the prevalence and correlates of HIV, hepatitis C, and HIV/HCV co-infection in a large, multisite sample of SMI clients. We conducted a re-analysis of data on prevalence and correlates of blood-borne infections in a multisite sample of SMI clients. In 1997-1998, 755 SMI clients were tested for HIV, hepatitis B virus and HCV, and assessed for demographic, illness-related and other behavioral risk factors for blood-borne infections. The prevalence and correlates of co-infection were examined, as well as the knowledge, attitudes and risk behaviors of individuals with HCV mono-infection. Of the 755 participants, 623 (82.5%) were negative for both HIV and HCV, 23 (3.0%) were positive for HIV, 109 (14.4%) were positive for HCV, and 13 (1.7%) were co-infected with HIV and HCV. Overall, 2.5% of dually diagnosed participants were co-infected, whereas only 0.6% of SMI participants without a comorbid SUD diagnosis were co-infected. Co-infection was associated with psychiatric illness severity, ongoing drug abuse, poverty, homelessness, incarceration, urban residence and minority status. HCV-mono-infected clients continued to engage in high levels of risk behavior for HIV. In addition to efforts to identify and treat SMI patients with HIV/HCV co-infection, HCV-mono-infected clients should be targeted for prevention interventions.